QUALITY OF CARE IN FRAGILE, CONFLICT-AFFECTED AND VULNERABLE SETTINGS

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QUALITY OF CARE IN FRAGILE, CONFLICT-AFFECTED AND

VULNERABLE SETTINGS

TOOLS AND RESOURCES COMPENDIUM

QUALITY OF CARE IN FRAGILE, CONFLICT-AFFECTED AND

VULNERABLE SETTINGS

TOOLS AND RESOURCES COMPENDIUM

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QUALITY OF CARE IN FRAGILE, CONFLICT-AFFECTED AND

VULNERABLE SETTINGS

TOOLS AND RESOURCES COMPENDIUM

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Quality of care in fragile, conflict-affected and vulnerable settings: tools and resources compendium ISBN 978–92–4-001800–6 (electronic version)

ISBN 978–92–4-001801–3 (print version)

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Design and layout by Inis Communication

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The Quality of care in fragile, conflict-affected and vulnerable settings: tools and resources principal writing team consisted of Laura Simpson, Matthew Neilson and Shams Syed. It was developed under the overall technical direction of Shams Syed, Quality Lead within the Department of Integrated Health Services, World Health Organization (WHO) headquarters, Geneva.

The content draws heavily on the WHO Handbook for national quality policy and strategy and other relevant WHO technical content related to the emerging work on quality in the context of fragile, conflict-affected and vulnerable (FCV) settings.

Substantial foundational work to support development of this document has been provided by Sheila Leatherman and a team including Maggie Holly, Dilshad Jaff, Grace Jaworski, Charlotte Lane, Sheila Patel, Jen Stutsman, and Linda Tawfik, and assisted by additional colleagues at the Gillings School of Global Public Health at the University of North Carolina, USA.

Ongoing review, scoping, feedback, and contributions were received by WHO NQPS Team members at different stages of the process: Nana Mensah Abrampah, Neha Dhawan, Ruben Frescas, Sepideh Bagheri Nejad, Linda Tawfik, and Florian Tille.

Valuable inputs in the form of contributions, peer review and suggestions were provided by:

Bruce Agins, Yolanda Agra, Suad Eltahir Ali Ahmed, Onyema Ajuebor, Khaldoun Alamire, Mwanaali Haji Ali, Micaela Arthur, Gertrude Avortri, Nisha Keshary Bhatta, Barbara Lopes Cardozo, Alessandro Cassini, Philip Crowley, Nino Dayanghirang, Monica Dea, Paulina Pacheco Estrello, John Fitzsimons, Anna Freeman, Dominic Dormenyo Gadeka, Sandra Gewalt, Odet Sarabia González, Wael Hatahit, Breeda Hickey, Keely Jordan, Stephanie Kandasami, Vijay Kannan, Peter Lachman, Andrew Likaka, Bruno Lucet, Queena Luu, Birgitta Lytsy, Ruth Madison, Hema Magge, Anatole Manzi, M. Rashad Massoud, Catherine McGowan, Maggie Montgomery, Mari Nagai, Edgar Necochea, Raymond Okechukwu, Kamal Olleri, Hans Onya, Kate Onyejekwe, Eba Pasha, Nigel Pearson, Eman Radwan, Alexander Rowe, Sujoy Roy, Samina Sana, Karin Saric, Dan Schwarz, Manuel Kassaye Sibhatu, Fiona Stephenson, Ayda Taha, Tara Talvacchia, Lekilay Tehmeh, David Weakliam, Sara Yaron, and Evgeny Zheleznyakov.

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Abbreviations

AMR antimicrobial resistance AMS antimicrobial stewardship

BPHS basic public health service package DRC Democratic Republic of Congo EPHS Essential Package of Health Services

HeRAMS Health Resources and Services Availability Monitoring System HRH human resources for health

IAWG Inter-Agency Working Group

ICRC International Committee of the Red Cross

IFRC International Federation of Red Cross and Red Crescent Societies IMAI integrated management of adolescent and adult illness

IPC infection, prevention and control IRC International Rescue Committee

LSHTM London School of Hygiene and Tropical Medicine NCDs noncommunicable diseases

NHQS national health quality strategy NQPS national quality policy and strategy

OECD Organisation for Economic Co-operation and Development

PHC primary health care

PSFHI Patient Safety Friendly Hospital Initiative SATS South African triage scale

SBAR situation background assessment recommendation SRH sexual and reproductive health

UHC universal health coverage

UN United Nations

UNHCR United Nations High Commissioner for Refugees UNICEF United Nations Children’s Fund

UNWRA United Nations Relief and Works Agency for Palestine Refugees in the Near East USAID United States Agency for International Development

WASH Water, sanitation and hygiene WHO World Health Organization

WHO-PEN WHO Package of essential noncommunicable disease interventions

v Abbreviations

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In brief

The Quality of care in fragile, conflict-affected and vulnerable settings: tools and resources compendium represents a curated, pragmatic and non-prescriptive collection of tools and resources to support the implementation of interventions to improve quality of care in such contexts. Relevant tools and resources are listed under five areas: Ensuring access and basic infrastructure for quality; shaping the system environment; reducing harm; improving clinical care; and engaging and empowering patients, families and communities. Cross-cutting products are also signposted.

Who is it for?

A range of stakeholders working in fragile, conflict-affected and vulnerable settings, including but not limited to humanitarian agencies and their coordination bodies (for example the national Health Cluster), ministry of health personnel at national and district levels, public and private health care provider organizations, non-governmental organizations, managers, system leaders and practitioners – as they all work towards improving quality of care.

Why was it developed?

The compendium is a companion to the World Health Organization (WHO) resource Quality of care in fragile, conflict-affected and vulnerable settings – taking action. It provides signposts to further resources that support practical action around implementation of quality-related interventions.

How was it developed?

A process of several rounds of scoping searches, tools identification and refinement by the WHO National Quality Policy and Strategy (NQPS) team; collaboration and co-development with technical and humanitarian partners; and focus on meeting priority, context-specific and practical needs have guided the compendium development process. Tools and other resources have been sought based primarily on their utility in supporting implementation of evidence-based interventions for improving quality in fragile, conflict-affected and vulnerable settings.

How should it be used?

The compendium is intended for use in support of the processes outlined in Quality of Care in fragile, conflict-affected and vulnerable settings: Taking action, alongside other WHO knowledge products such as the Handbook for national quality policy and strategy and the National quality policy and strategy tools and resources compendium.

vi Quality of care in fragile, conflict-affected and vulnerable settings: tools and resources compendium

NATIONAL QUALITY POLICY AND STRATEGY

TOOLS AND RESOURCES COMPENDIUM HANDBOOK FOR NATIONAL QUALITY POLICY AND STRATEGY

A practical approach for developing policy and strategy to improve quality of care

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Introduction and background

Quality of care is recognized as central to achieving universal health coverage (UHC) and Sustainable Development Goal 3.8, and is therefore fundamental to improving population health outcomes (1–4).

In order that UHC becomes realistically attainable, the provision of quality services to all people in all settings must be considered and strived for.

It is estimated that two billion people globally are living in settings considered to be fragile, conflict- affected and vulnerable (1). The term ‘fragile, conflict-affected and vulnerable’ broadly describes situations of crisis induced by a variety of factors. While there is no widely accepted global definition, such settings are generally seen to include all those experiencing humanitarian crises, protracted emergencies, or armed conflict.

The WHO resource Quality of Care in fragile, conflict-affected and vulnerable settings: Taking action (5) and this accompanying tools and resources compendium have been developed as a means to support efforts and actions to address quality of care, with acknowledgement of the urgent practical, and context-specific needs and challenges related to quality of care in fragile, conflict-affected and vulnerable settings. At the core of this work lies an unmet and critical need for support in action planning for quality of care. This includes practical approaches to the implementation of interventions that are intended to improve quality in fragile, conflict-affected and vulnerable settings, taking due account of the particular challenges and contexts of such environments.

The Taking action document (5) and the supporting tools and resources that follow in the current resource, build on the technical foundation derived from the WHO National Quality Policy and Strategy (NQPS) initiative and an emerging academic evidence base, in addition to experiential knowledge from the field and expert consultation. This document is closely aligned with other resources developed as part of the WHO NQPS initiative, including the Handbook for national quality policy and strategy:

a practical approach for developing policy and strategy to improve quality of care (6) and the National quality policy and strategy tools and resources compendium (7). It is intended to be used alongside these documents.

1 Introduction and background

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Accessing the tools and resources

To connect users directly to relevant items, hyperlinks for each suggested tool or resource have been provided within the current compendium. Should a tool or resource not be freely available online, the hyperlink will lead to the WHO Global Learning Laboratory for Quality UHC (Global Learning Laboratory), where these items are housed. The Global Learning Laboratory is an interactive knowledge platform designed as a safe space to share lessons, frontline experiences and ideas, challenge those ideas and spark new thinking and innovation. The WHO NQPS initiative links very closely to the Global Learning Laboratory, as it provides an effective medium by which to share, discuss and refine tools and resources related to quality in the context of UHC.

If you are already registered with the Global Learning Laboratory, please click here to access

If you are not yet registered, please click here to find out more

3 Accessing the tools and resources

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Developing this compendium

The collection of tools and resources presented are based around the five quality intervention categories outlined in the Taking action document (5), and their constituent illustrative quality interventions, alongside an additional section housing ‘cross-cutting’ resources. These quality interventions have been selected based on a growing body of academic and experiential intelligence (9).

Table 1. Interventions in the five quality intervention categories

Category Illustrative interventions Ensure access

and basic infrastructure for quality

Ensure structural capacity and essential inputs

Negotiate terms for care provision and safe access

Provide access to mobile services

Contract out services

Strengthen health information systems for quality and performance

Optimize procurement and supply chain systems Shape the

system environment

Link quality action planning to a defined package of health services

Recruit and retain workforce with a focus on quality of care

Pre-verification of qualifications of health teams for deployment

Strengthen quality accountability mechanisms

Strengthen performance reporting for quality

Use performance-based contracting/commissioning

Implement financing methods to enhance quality based on context

Oversee quality of private sector provision of care

Assess facility capacity for delivery of quality services Reduce

avoidable harm

Strengthen infection prevention and control

Implement priority patient safety processes at the point of care

Provide hands-on patient safety training to health care workers

Use a context-specific patient safety risk management tool Improve

frontline clinical care

Use context-appropriate guidelines, standards and protocols

Routinely use quality monitoring and improvement processes

Provide training with supportive supervision and performance feedback for the health workforce

Strengthen primary care and referral networks to deliver quality services

Use clinical decision support tools

Use electronic/digital health technologies and programmes Engage and

empower patients, families and communities

Establish patients’ rights and complaints programmes

Formally engage and empower communities

Educate patients, families and communities

Provide peer support and counselling

Measure patient experience of care for service improvement

Use patient self-management tools

5 Developing this compendium

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The WHO NQPS team carried out scoping exercises for each quality area, and for each intervention.

This process involved definition of search criteria and sources, development of a set of inclusion criteria, and searching of open access resources. A request for tools and resources relevant to quality in fragile, conflict-affected and vulnerable settings was shared with technical colleagues from within WHO and externally, and via the Global Learning Laboratory through a focused co-development call. A subsequent further request for tools and resources and feedback was made during a consultation process.

Each resource identified as part of these exercises has been carefully examined, appraised and discussed within the team to reach consensus prior to inclusion within the compendium. This process has been repeated over time. Careful consideration has been given to the practical benefit of these tools and resources through a quality of care lens. The aim of this process was to judiciously select those tools and resources that are most additive to practical efforts to address quality in fragile, conflict-affected and vulnerable settings and that are best suited to the context.

Where no suitable tools or resources were identified for a particular intervention, that intervention has not been listed in the table of resources. A list of those with no tools or resources included is available in the gap analysis presented on page 29.

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Scope and limitations of this Compendium

The definition of a fragile, conflict-affected and vulnerable setting encompasses a broad and variable range of crises and contexts. The tools and resources selected from this compendium for application in these varied settings will naturally vary depending on the situation in which they are being used.

It is not within the scope of this compendium to provide or suggest tools for every possible context, but the importance of selecting, adapting and applying the resources to best meet the needs of the local setting is emphasized.

Whilst appraised as being practical and relevant to implementing various interventions to support quality of care, many of the individual resources have not been rigorously tested by WHO. Some of the individual resources are several years old but have been appraised as remaining relevant for inclusion. Country case examples are included to represent approaches currently being used by countries but are not intended to be validated examples of best practice. We recognize, however, that case examples are valued and additive learning resources, and we hope to signpost to a wider variety of these as they become available (through further work on quality in fragile, conflict-affected and vulnerable settings).

The tools and resources that follow have been selected and refined based on their ability to be practically applied to support quality in fragile, conflict affected or vulnerable settings. For this reason, the current compendium does not seek to highlight particular quality improvement methodologies, but instead supports delivery of a pragmatic set of interventions to improve overall quality of health care delivery in fragile, conflict-affected and vulnerable settings. The compendium has been intentionally structured around a list of illustrative interventions to support practical action, as outlined in the accompanying Taking action document (5). Further tools and resources to support strategic action planning for quality can be found within the NQPS tools and resources compendium (7).

Particular emphasis and consideration have been given to identifying and prioritizing key gaps in currently available and accessible tools and resources, in order to guide the direction of further development of the compendium within this rapidly evolving area of work. Addressing these gaps will be based on iterative learning and as the experiential knowledge base continues to grow. An initial gap analysis is presented at the end of this document to highlight areas of need for further tools identification and potential future development.

7 Scope and limitations of this Compendium

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Quality in settings of fragility, conflict and vulnerability: tools and resources compendium

Cross-cutting tools and resources

This section contains tools and resources relevant across more than one quality area, or with broader relevance to quality in fragile, conflict affected and vulnerable environments.

Resource(s) Institution(s)/

author(s) and year How does the tool/resource support quality?

Handbook for national quality policy and strategy A practical approach for developing policy and strategy to improve quality of care

National quality policy and strategy tools and resources compendium

WHO 2018 and 2019 The WHO NQPS initiative seeks to support countries in improving the performance of their health systems through the development and execution of national quality policies and strategies.

The WHO Handbook for national quality policy and strategy provides the technical foundation for this initiative. It outlines a strategic approach for quality based on eight inter-related elements.

The NQPS tools and resources compendium was developed alongside the Handbook and presents a curated collection of practical tools and resources to support the development and implementation of this strategic approach to improving quality of care.

Although nationally-led solutions are unlikely to be the starting point in many fragile, conflict-affected and vulnerable settings, the same eight-element approach can provide important framing for a context-specific, strategic approach to action planning for quality of care in such settings.

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Effective primary care during extreme adversity: Building on Astana to meet the needs of all Available on the Global

Learning Laboratory:

Registered? Click here to access

Not registered?

Click here to find out more

Lisa Hirschhorn 2019 Presentation made at Expert Consultation on the Development of an Implementation Framework for Quality and Safety during Adversity and Emergencies, Muscat, Oman in 2019.

Discusses quality and effective primary health care (PHC) during extreme adversity, including relevant examples as they relate to the functions of quality PHC. The presentation notes that many themes for quality in extreme adversity are similar to the functions and goals of PHC, including effectiveness and efficiency, patient centeredness, equity and a range of needs.

It goes on to discuss the challenges and recommended approaches for three levels of emergencies adapted from Healthcare quality and patient safety in settings of extreme adversity and notes the primary care functions in these settings, aligning the recommendations and priorities with the six functions of quality PHC.

Sphere handbook

Chapter 8. Health The Sphere Project

2018 The Sphere handbook is targeted towards any agent involved in a humanitarian response.

The health chapter, specifically, describes the processes needed to warrant high quality health care services in an emergency context. Key areas of focus include health service delivery, communicable diseases, child health, sexual and reproductive health, trauma care, mental health, noncommunicable diseases, and palliative care.

The annex contains a health assessment checklist, sample surveillance forms, and formulas for calculating key health indicators.

The handbook is available in Arabic, English, French and Spanish.

Inter-agency field manual on reproductive health in humanitarian settings

Inter-Agency Working Group on Reproductive Health in Crises (IAWG) 2018

The IAWG comprises over 2100 representatives from 450 agencies including UN and

nongovernmental, humanitarian, development, research and advocacy organizations.

This manual incorporates specific evidence from the application and adaptation of global sexual and reproductive health (SRH) or human rights standards in humanitarian settings, and recommends evidence-based interventions based on international guidelines.

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It outlines best practices in providing high quality SRH services in humanitarian settings, including comprehensive patient education, community involvement to increase successful service delivery, and care for survivors

of sexual violence. It also makes specific mention of fundamental principles of health planning in fragile environments, and logistical considerations relevant to fragile, conflict- affected and vulnerable settings. Available in Arabic, English and French

Technical series on primary health care: Primary health care and health emergencies

WHO 2018 This briefing document was produced as part of the Technical series on primary health care on the occasion of the Global Conference on Primary Health Care in 2018. Discusses the pivotal role of primary health care in humanitarian emergencies. Brief discussion of opportunities for action/emergency preparedness with a focus on quality of care.

Situation background assessment

recommendation (SBAR)

Communication tool

National Health Service (UK) Improvement 2018

This tool provides an overview of the SBAR approach to structured communication and handover in health care settings. The resource includes guidance on how to implement the SBAR approach. This approach may be helpful to support improvement in communication processes in a range of settings, contributing to quality care.

COMPASS for Health

Nutrition and WASH Save the Children

UK 2018 COMPASS is an online platform developed by Save the Children UK. It houses standardized programming guidelines on a variety of topics including community, mass delivery, HIV/TB, and topics relevant to primary and secondary care. COMPASS modules define the scope of each intervention supported by detailed practical information including: implementation tips, integration opportunities, indicators, clinical forms, auditing activities, job descriptions and procurement lists.

Developed for use by Save the Children staff as guidance to support their programme interventions, and also contains relevant and practical information that could be applied elsewhere. Also available as a mobile app.

Doctors working in conflicts and emergencies – an ethical toolkit

British Medical

Association 2017 This toolkit helps prepare physicians on issues they may face while working in conflict and emergency settings. Guidelines and hints are provided on various topics such as: working with limited resources and identifying an adequate lower limit of quality through practical scenarios that represent ethical dilemmas many health workers face in such contexts.

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Caring for child survivors of sexual abuse: Guidelines for health and psychosocial service providers in humanitarian settings

IRC and UNICEF

2012 This handbook outlines a child-centered model of care to be used particularly in humanitarian settings. It also includes guidance and tools for children’s families and caring for child survivors.

Hospital emergency response checklist An all-hazards tool for hospital administrators and emergency managers

WHO 2011 This tool supports hospital managers and administrators to prepare for, assess and rapidly respond to the challenges placed on health facilities by emergencies and disasters. Provides a checklist of recommendations and priority actions, and signposts to other relevant sources of guidance on each topic.

Rebuilding health systems and providing health services in fragile states

Management Sciences for Health 2007

This conceptual piece highlights health as an entry point for effective engagement with fragile states. It also gives a helpful overview of the concepts around fragility, service delivery and system development in these environments and discusses donor models of engagement, emphasizing the fact that short-term relief should always be offered with a view to longer- term contribution and support.

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Ensure access and basic infrastructure for quality

Access and quality are undoubtedly interdependent. The existence of functioning service delivery platforms and the ability of affected populations to equitably access and use services are clear prerequisites for any effort to improve care in fragile, conflict-affected and vulnerable settings. The resources in this category are intended to support critical foundations for quality related to physical infrastructure, service availability and population access.

Ensure structural capacity and essential inputs Water, sanitation, and

hygiene in health care facilities: practical steps to achieve universal access to quality care

WHO, United Nations Children’s Fund (UNICEF) 2019

Water, sanitation and hygiene (WASH) within health facilities is a critical foundation for delivery of quality care. This document outlines a series of practical steps that can be taken to assess and improve WASH in health care facilities, under a number of action areas.

Water and sanitation for health facility

improvement tool (WASH FIT): A practical guide for improving quality of care through water, sanitation and hygiene in health care facilities

WHO, UNICEF 2017 The WASH FIT tool provides methodological guidance on improving and sustaining WASH services in low- and middle-income countries. The toolkit also provides resources for national or district level policy-makers and implementers such as a timeline template, sample questionnaire, and best practices on how to design a WASH FIT training package.

Improving WASH service delivery in protracted crises South Sudan

Democratic Republic of Congo (DRC)

Overseas Development Institute 2016

Methods for facilitating better complementarity between humanitarian and development approaches in crisis situations to improve WASH service delivery are examined in these studies. WASH interventions in DRC and South Sudan are analysed and recommendations for action at the sub-national and national level are provided.

Comprehensive safe hospital framework Hospital safety index guide for evaluators

WHO 2015 These resources outline a structured

approach to safeguard the ability of hospitals to continue providing services when faced with emergencies and disasters. Actions are outlined to support resilience and preparedness of hospitals, protect health workers and patients, and protect the physical infrastructure and systems.

Public health engineering in precarious situations Available on the Global Learning Laboratory:

Not registered? Click here to find out more

Médecins Sans Frontières (MSF) 2010

This handbook outlines a series of simple and cost-effective measures that can be applied to improve access to WASH. It includes assessment and planning tools for WASH in health care facilities in fragile, conflict-affected and vulnerable settings, and also covers related topics such as medical waste management.

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Negotiate terms for care provision and safe access Health care in danger

(Resource centre) Relevant

resources include:

Promoting military operational practice that ensures safe access to and delivery of health care

The implementation of rules protecting the provision of health care in armed conflicts and other emergencies: a guidance tool

Security survey for health facilities

A matter of life and death: tackling

violence against health care in Pakistan, Peru and El Salvador

International Committee of the Red Cross (ICRC) 2019

This website from the International Red Cross and Red Crescent movement presents a range of tools, resources and case studies related to ensuring health care services can continue to safely operate in situations of conflict. Within these resources are a number related to engagement with state and non-state actors to negotiate safety and security for health workforce, patients and families.

Occupational safety and health in public health emergencies: a manual for protecting health workers and responders

WHO 2018 Comprehensive manual detailing both managerial aspects and practical strategies for addressing various aspects of occupational safety and health including infectious

outbreaks, infection, prevention and control (IPC) for health workers, and violence and attacks against health facilities and staff. Also contains an annex with practical tools and resources to support suggested action.

Provide access to mobile services Mobile health units:

methodological approach

ICRC 2006 This document provides an overview of the mobile health unit (MHU) concept from the perspective of ICRC. Drawing on literature and field experience, it presents a range of factors to be considered when developing an MHU strategy, and outlines other key considerations related to start-up activities, logistics and decisions on whether an MHU is appropriate. Although developed in 2006, the considerations outlined remain relevant.

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Humanitarian

OpenStreetMap Team (HOT): Tools and data

Humanitarian OpenStreetMap Team

Intended to support and facilitate humanitarian response to emergencies and disasters and provide information for humanitarian and other actors working in vulnerable settings, this resource provides freely available tools, data and information to support mapping for hard- to-reach places and communities. Examples include mapping of informal transport routes in Nicaragua, points of interest in Cox’s Bazar (including health facilities) and real time information on the road network in the Syrian Arab Republic. Users can contribute information, or request help to create new maps. The

information provided could be used to provide information regarding access to health facilities or to operationalize transport and mobile services in remote or hard-to-reach areas.

Contract out services Contracting out health services in post- conflict and fragile situations: Lessons from Cambodia, Guatemala and Liberia

Organisation for Economic Co-operation and Development (OECD) 2009

This chapter sits within a broader resource related to contracting out of government services in fragile environments. Lessons on contracting out health services have been collated and summarized, and a series of recommendations are presented to guide decisions on contracting health services in fragile environments.

Strengthen health information systems for quality and performance Health Resources and

Services Availability Monitoring System (HeRAMS)

WHO Health Resources and Services Availability Monitoring System (HeRAMS) is an approach to collecting of data on availability of health services in settings experiencing public health emergencies. In such settings, challenges with access and security may limit the collection of data on the availability of health services, which limits subsequent decision-making and strategic planning. HeRAMS is a practical approach to meeting that gap. The HeRAMS website provides further background information on the approach and the data it provides.

SPHERE handbook sample weekly surveillance reporting forms

SPHERE 2018 The SPHERE handbook on minimum standards in humanitarian response provides a series of sample surveillance reporting forms (pp351–

355) that can be used by health providers in humanitarian settings to collect and share key data on mortality, communicable diseases and outbreaks.

(Please see the Cross-cutting tools section for the full entry on the SPHERE handbook).

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Outbreak surveillance and response

in humanitarian emergencies: WHO guidelines for EWARN implementation

WHO 2012 The Early Warning and Response Network (EWARN) acts as an adjunct to national disease surveillance systems to facilitate effective surveillance and communicable disease control in emergencies. This document outlines how EWARN can be implemented following humanitarian emergencies.

The use of

epidemiological tools in conflict-affected populations: open- access educational resources for policy-makers

London School of Hygiene and Tropical Medicine (LSHTM) 2009

This is an online handbook outlining key considerations and practical approaches for epidemiology in crises. It includes notes on performing surveys, analysing data, and analysing health service performance.

Health information systems in humanitarian emergencies

Bulletin of the World Health Organization 2005

This academic paper provides an overview of information needs and data collection approaches in humanitarian emergencies. In the context of efforts to improve quality of care, the paper may help readers to understand common challenges and guide assessment and improvement of information systems.

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Shape the system environment

Quality care depends not only on interventions focused on care processes and service delivery, but also on efforts to create the supportive conditions, governance processes and culture necessary to enable providers and professionals to meet the desired levels of care. This includes a strong focus on the capacity of the health workforce to deliver quality care, as well as accountability mechanisms linked to assessment against defined quality standards.

Link quality action planning to a defined package of health services Working paper on

the use of essential packages of health services in protracted emergencies

Global Health Cluster, Task Team on Essential Package of Health Services (EPHS) 2018

Following a desk review of existing essential packages of health services, this working paper was developed by the Global Health Cluster Task Team on Essential Package of Health Services. It sets out a six-step process that can be used to create, implement and monitor an EPHS in settings affected by protracted emergencies. It emphasises the importance of flexibility and adaptation of the EPHS in diverse environments, essential in order to restore and maintain access to essential health services for populations in these settings.

A basic health services

package for Iraq (Country example)

Iraq Ministry of

Health, WHO 2010 This country example details the essential package of basic health services developed to reform access to primary health care in Iraq.

It comprises a situational analysis, discussion of the development for the basic public health services package (BPHS), considerations for implementation of the BPHS in the long and short term and annexes detailing components of the package such as essential medicines, human resources, equipment and services provided.

A basic package of health services for Afghanistan, 2005/1384 Available on the Global

Not registered?

Islamic Republic of Afghanistan Ministry of Public Health 2005

The BPHS for Afghanistan sets out the services that should be provided by each type of PHC facility in the Afghan health system: health posts, health centres and district hospitals, and specifies the human resources, equipment, diagnostic services and medications required in order to provide those services.

The Essential Package of Hospital Services for Afghanistan is modelled upon the BPHS and developed to improve the quality of hospital services in the country. The academic paper Afghanistan’s basic package of health services:

its development and effects on rebuilding the health system from Global Public Health 2014 further discusses the development of the basic package of health services in Afghanistan.

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Recruit and retain workforce with a focus on quality of care Maintaining an

effective health workforce during and after conflict:

Evidence from

ReBUILD’s research in northern Uganda

ReBUILD Consortium

2016 This brief summary presents evidence and findings from an area of ReBUILD Consortium’s research in northern Uganda. This work on the maintenance of an effective health workforce during and after conflict, examined the impact of incentive policies and practices. It sets out key messages that may be drawn from in other conflict-affected settings.

A comprehensive framework for human resources for health system development in fragile and post- conflict states

PLOS Medicine 2011 (open access peer reviewed publication)

This paper presents a suggested framework for human resources for health (HRH) system development based on experiences from fragile health systems in Afghanistan, Cambodia and the Democratic Republic of Congo .

Guide to health workforce

development in post- conflict environments

WHO 2005 Designed to assist in re-establishing health services in countries emerging from conflict, this document provides practical guidance related to rebuilding a health workforce and provides detailed guidance for human resources personnel working to re-establish HRH in settings such as Cambodia and Timor Leste.

Pre-verification of qualifications of health teams for deployment Classification and

minimum standards for foreign medical teams in sudden onset disasters

Foreign Medical Teams Working Group, Global Health Cluster, WHO 2013

Acknowledging the critical need for an organized response from foreign medical teams deployed in the aftermath of sudden onset disasters, this document presents tools to support the coordination of teams that may provide urgent surgical and trauma care in such situations. These include a simple classification system, set of minimum technical standards and example self-registration

documentation. While the approach detailed here specifically applies to sudden onset disasters, the principles may be usefully applied in other settings.

Strengthen quality accountability mechanisms Hard to reach:

Providing healthcare in armed conflict

International Peace

Institute 2018 This document provides a very useful and relevant overview of some of the challenges associated with health care delivery in areas affected by armed conflict. Includes a helpful section that discusses the accountability- related concepts in this context.

Strengthen performance reporting for quality A balanced scorecard

for health services in Afghanistan

Bulletin of the World Health Organization, 2007

This paper discusses the use of a balanced scorecard to monitor and evaluate the delivery of the BPHS in Afghanistan.

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Use performance-based contracting/commissioning Performance-based

contracting for health services in developing countries

A Toolkit

World Bank 2008 While not specifically for fragile, conflict-affected and vulnerable contexts, this World Bank toolkit provides an overview and step-by-step approach for designing and implementing performance- based contracting for health services. The approach and principles outlined are likely to be of use for those planning performance-based contracting in fragile, conflict-affected and vulnerable contexts, though adaptation will be required for the particular challenges and needs of each setting.

Implement financing methods to enhance quality based on context Health financing

policy and

implementation in fragile and conflict- affected settings:

a synthesis of evidence and policy recommendations

WHO 2019 This paper examines existing WHO health financing policy and guidance in support of UHC and considers them in the context of fragile, conflict-affected and vulnerable settings. It presents evidence for recommendations to inform policy for health financing and service delivery for these environments.

Oversee quality of private sector provision of care Engaging the private

sector in PHC to achieve UHC: Advice from implementers to implementers

Joint Learning Network for Universal Health Coverage 2016

This practical manual outlines an approach to engaging and collaborating with the private sector in providing primary health care services.

Contains useful information that could be usefully applied to other clinical topic areas outside of PHC and includes country examples of successful collaborative efforts. Those overseeing the health sector in fragile, conflict- affected and vulnerable settings may find advice and examples to guide their efforts to effectively oversee private sector provision of care.

Assess facility capacity for delivery of quality services Minimum standards

facility assessment tool Available on

the Global

Not registered?

MSF 2019 This document comprises a detailed facility assessment tool developed by MSF for use in hospitals and designed for use as part of a comprehensive quality assessment process. A practical example of the considerations that can be given attention when developing such a tool.

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Iraq Quality of Care Tool – Primary Health Care Centre

Available on the Global

Not registered?

WHO Iraq, Global

Health Cluster 2018 This tool has been developed and applied internally by WHO Iraq and Global Health Cluster technical teams using a balanced scorecard approach for assessing the quality and provision of health services in refugee camps established and managed under the auspices of the United Nations High Commissioner for Refugees (UNHCR) (further information available here). It includes a health facility assessment tool, a health worker interview tool and a patient satisfaction questionnaire.

HEALTHQUAL organizational quality assessment tool

Healthqual (University of California, San Francisco) 2018

This resource provides a clear and comprehensive checklist-based quality assessment tool, that can be used to evaluate various types of health facility, or a specific sub-area e.g. disease programme.

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Reduce avoidable harm

These interventions focus on key activities aimed at upholding the foundational principle of causing no avoidable harm to the populations receiving health services. Achieving this requires multimodal and multidisciplinary action to implement a range of practical tools, while concurrently addressing the behavioural and cultural change required to build a sustainable, safe environment.

Strengthen infection prevention and control WHO infection

prevention and control evidence, guidelines and publications WHO infection

prevention and control implementation tools and resources Of particular note:

WHO minimum requirements for infection prevention and control

programmes

Guidelines on core components of infection prevention and control

programmes at the national and acute health care facility level, an associated Facility assessment tool and Practical manual

WHO 2019 WHO has developed a suite of tools and resources to support implementation of critical actions for infection prevention and control (IPC). Given the foundational nature of IPC, most of these have direct relevance to fragile, conflict-affected and vulnerable settings. A variety of guidelines, self-assessment tools, communications materials and other technical resources are provided, covering a range of topics including hand hygiene, surgical site infection, injection safety and antimicrobial resistance (AMR).

Antimicrobial stewardship

programmes in health- care facilities in

low- and middle-income countries: a WHO practical toolkit

WHO 2019 Antimicrobial stewardship (AMS) and prevention of antimicrobial resistance is of critical importance to health systems strengthening and has close interlinkages with infection prevention and control and patient safety processes in all contexts including fragile, conflict-affected and vulnerable settings.

This manual outlines practical and strategic actions for planning and implementing AMS programmes in various settings and across the different levels of the health system.

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Implement priority patient safety processes at the point of care WHO Emergency Checklists:

WHO Trauma care checklist

WHO Medical emergency checklist

WHO 2020 The WHO Trauma care checklist is a simple tool that emphasises key actions at two critical points during the initial care of a patient presenting with serious injury, with a focus on implementing timely interventions to reduce mortality.

The WHO Medical emergency checklist is a modified version of the WHO Trauma care checklist that is adapted for use with patients with acute conditions other than injury.

These resources can be easily adapted by emergency units to best suit local needs, and are both appropriate for use in fragile, conflict- affected and vulnerable settings.

Patient safety essentials

toolkit Institute for

Healthcare Improvement 2019

A collection of nine practical patient safety interventions. Each tool is explained in detail, containing examples or templates for use.

Although not designed with fragile, conflict- affected and vulnerable environments specifically in mind, these tools could be suitable for application in these settings.

5 moments for

medication safety WHO 2019 5 Moments for medication safety is a patient engagement tool developed to support

implementation of the third WHO Global Patient Safety Challenge: Medication Without Harm It focuses on five key moments where action by the patient or caregiver can reduce the risk of harm associated with the use of medication/s.

This tool aims to engage and empower patients to be involved in their own care. It should be used in collaboration with health professionals, but should always remain with the patients, their families or caregivers.

Medication safety in key

action areas WHO 2019 To support countries to implement the Global Patient Safety Challenge: Medication Without Harm, WHO has produced a series of technical reports to facilitate planning to address three key issues for medication safety:

medication safety in transitions of care

medication safety in polypharmacy

medication safety in high-risk situations

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WHO Safe childbirth

checklist WHO 2015 This tool is intended to improve the quality of care for women and babies at the time of childbirth.

It provides a clear and simple list of evidence- based clinical activities targeting major causes of maternal and neonatal morbidity and mortality that occur around the world.

The WHO Safe childbirth checklist implementation guide has been developed to facilitate successful implementation of the checklist.

Patient Safety Friendly

Hospital Initiative WHO Regional Office for the Eastern

Mediterranean 2011

The Patient Safety Friendly Hospital Initiative (PSFHI) is a systematic evaluation tool that addresses the burden of unsafe care in the Eastern Mediterranean Region. It helps

institutions in countries of the Region to launch comprehensive patient safety programmes, with support from WHO.

The PFSHI is supported by two practical tools:

Patient safety assessment manual

Designed to provide practical guidance on the identification of patient safety needs, and self- improvement. Successfully applied in fragile, conflict-affected and vulnerable settings in the Eastern Mediterranean Region.

Patient safety toolkit

This is a consolidated resource outlining a practical approach to a range of key patient safety processes, including those related to patient identification, safe surgery, and establishing reporting systems.

WHO best practices for injections and related procedures toolkit

WHO 2010 This toolkit supports safe and appropriate use of injections in health care settings. It provides an overview of standard precautions aimed at ensuring injection practices do not harm the recipient or provider, and do not result in waste that causes risk to other people.

WHO Surgical safety

checklist WHO 2009 The WHO Surgical safety checklist comprises 19 items that have proven successful in decreasing errors and adverse events and in improving teamwork and communication in surgery. Widely used in a variety of surgical settings globally and could be adapted to serve as an effective tool in fragile, conflict-affected and vulnerable environments.

The WHO Surgical safety checklist implementation manual has been developed to help ensure successful implementation of the checklist.

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Patient safety solutions WHO 2007 This WHO web-based collection presents a series of standardized tools to support implementation of patient safety processes within health care settings. Each of

the resources outlines the background to the particular patient safety issue, suggested actions, and key considerations for implementation.

Provide hands-on patient safety training to health care workers WHO Patient safety

curriculum guide: Multi- professional edition

WHO 2011 This multi-professional guide is structured around various patient safety related topics.

Topics 5 and 6 give practical guidance on setting up an error reporting and learning system.

Use a context-specific patient safety risk management tool Learning without

borders: A review of the implementation of medical error reporting in Médecins Sans Frontières

MSF 2015 This paper presents an analysis of the first three years of a medical error reporting system in MSF. It includes lessons learned, a description of how the system was implemented, and links to related tools.

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Improve frontline clinical care

This category of interventions focuses on processes and tools aimed at increasing the effectiveness of clinical care. This incorporates collaborative, supportive quality-focused processes to monitor and improve health worker practice as well as practical resources that can be used to support diagnosis and management at the point of care.

General

PEN-Plus: Toolkit for outpatient care of severe, chronic, noncommunicable diseases at first-level hospitals

Partners in Health

2015 This online toolkit draws on experiences in Haiti, Liberia, Malawi and Rwanda, where Partners in Health have been supporting the development of specialised clinics for care of noncommunicable diseases (NCDs) over many years. It is intended to supplement existing materials and approaches focused on primary health centres, including the WHO Package of essential noncommunicable disease interventions (WHO PEN), integrated management of adolescent and adult illness (IMAI) and others. It is based around seven topic areas relevant to these activities, each of which has implementation tools available in an editable format that can be adapted to local contexts. These include a framework for clinic guideline development, evaluation tools and information on referral pathways.

Use context-appropriate guidelines, standards and protocols

Normative guidance on a comprehensive range of clinical topics has been developed by WHO and is freely available. It is not within the scope of this compendium to document all relevant clinical guidelines, standards and protocols here, and there is currently no list of WHO- endorsed guidelines specific to provision of care in fragile, conflict-affected and vulnerable settings. Relevant guidelines, standards and protocols should be identified and utilized with consideration of each particular context.

Provide training with supportive supervision and performance feedback for the health workforce

Joint integrated supportive supervision tools – Liberia

Available on the Global Learning Laboratory:

United States Agency for International Development (USAID) 2018

An example of comprehensive supportive supervision tools for country, district and national level. Within Liberia’s current national health quality strategy (NHQS): “Supportive supervision is driven at the county level using structured tools including the Joint integrated supportive supervision tool; findings are shared with program heads for follow-up and action based on structured feedback and development of QI plans.”

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Mentorship and enhanced supervision for healthcare and quality improvement

Partners in Health

2017 This document provides direction to organizations and governments that are developing integrated clinical mentorship and quality improvement programmes. It is based on experiences from implementing and continuously improving the Mentorship and enhanced supervision for healthcare and quality improvement (MESH-QI) model in Rwanda, and informed by early lessons learned from adaptations in multiple settings. Also includes a practical resource guide that includes reference documents, job descriptions and protocols for diverse settings. This supports and encourages users to customize the resources and

approaches to local contexts, based on their goals for impact and system improvement.

The Quality care toolbox Available on the Global Learning Laboratory:

MSF 2014 A collection of practical clinician observation and feedback tools specific to quality of care.

Contains explanatory guidance on carrying out the assessments and analysis of the results. Also clearly highlights the limitations of each tool.

Strengthen primary care and referral networks to deliver quality services Newborn health in

humanitarian settings:

Field guide

Save the Children,

UNICEF 2017 This field guide provides guidance and tools to support implementation of good quality newborn health services in humanitarian settings, in order to reduce neonatal mortality and morbidity. It is a programming and advocacy tool, not a clinical guide.

This document has a clear focus on improving quality of care for mothers and newborns in the neonatal period (first 28 days of life), but also contains chapters dedicated to strategic and implementation considerations, including the development of an effective referral system.

Use clinical decision support tools Interagency integrated

triage tool

Available within the WHO Clinical care for severe acute respiratory infection toolkit

WHO 2020 WHO has produced a set of clinical decision support tools to aid health professionals in triage and assessment of patients attending emergency care settings. Of particular note is the Interagency integrated triage tool, which includes a series of triage protocols co-developed by MSF, ICRC and WHO. The tool is designed to create a common language to save a maximum number of lives by triaging patients effectively.

QUALITY OF CARE IN FRAGILE, CONFLICT-AFFECTED AND VULNERABLE SETTINGS

QUALITY OF CARE IN FRAGILE, CONFLICT-AFFECTED AND

VULNERABLE SETTINGS

TOOLS AND RESOURCES COMPENDIUM

QUALITY OF CARE IN FRAGILE, CONFLICT-AFFECTED AND

VULNERABLE SETTINGS

TOOLS AND RESOURCES COMPENDIUM

QUALITY OF CARE IN FRAGILE, CONFLICT-AFFECTED AND

VULNERABLE SETTINGS

TOOLS AND RESOURCES COMPENDIUM

Contents

Acknowledgements

Abbreviations

In brief

Who is it for?

Why was it developed?

How was it developed?

How should it be used?

Introduction and background

Accessing the tools and resources

Developing this compendium

Scope and limitations of this Compendium

Quality in settings of fragility, conflict and vulnerability: tools and resources compendium

Cross-cutting tools and resources

Ensure access and basic infrastructure for quality

Shape the system environment

Reduce avoidable harm

Improve frontline clinical care